- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $268.54 / $268.54 / $268.54
| Facility | | $268.54 | $268.54 | $268.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $356.20 / $510.03 / $1,065.58
| Facility | | $356.20 | $510.03 | $1,065.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $498.93 / $814.35 / $8,250.46
| Facility | | $498.93 | $814.35 | $8,250.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.62 / $480.41 / $611.16
| Professional | | $354.62 | $480.41 | $611.16 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $105.52 / $105.52 / $105.52
| Professional | 80 | $105.52 | $105.52 | $105.52 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $105.52 / $105.52 / $105.52
| Professional | AS | $105.52 | $105.52 | $105.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,143.00 / $3,143.00 / $3,143.00
| Facility | | $3,143.00 | $3,143.00 | $3,143.00 |